Effects of aerobic exercise on asthma control and quality of life in adults: a systematic review

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Summary of characteristics of randomized controlled trials included.

Authors	Study design	Subjects studied	Intervention parameters, duration, frequency	Participants	Control/Intervention age, years, mean (SD)	Outcome measures	Results
Franca-Pinto et al. [7)	RCT	Outpatients with moderate or severe persistent asthma aged 20-59 yrs from a University Hospital.	Indoor treadmill aerobic exercise to target 85% of maximal heart rate. 35 min twice a week for 12 weeks.	A total of 43 patients with asthma, with 21 in the control group and 22 in the intervention group.	Control: 44 (9) Intervention: 40 (11)	Clinical control based on symptom-free days ACQ AQLQ Bronchial hyperreactivity Inflammatory cytokines Induced sputum PFT Exercise capacity	Compared to the control group, the treatment group had an increased number of symptom-free days, higher AQLQ scores, lower bronchial hyperreactivity, lower IL-6 levels, and increased VO2 max and aerobic power.  There were no significant changes in induced sputum and FeNO, other inflammatory cytokines, or PFT in either group after the intervention.
Meyer et al. [8)	RCT	Adult patients with asthma in the Hamburg metropolitan area	Standardized aerobic training program with a target of > 60% of maximal heart rate. 60 min once a week for 12 months.	A total of 21 patients with asthma, with 8 in the control group and 13 in the intervention group.	Control: 59 (9) Intervention: 54 (11)	VO2 and work rate SF-36 AQLQ Peak flow	Compared to the control group, the treatment group showed improvement in their mean work rate, VO2 max, minute ventilation and oxygen pulse. SF-36 scores were improved in physical and social functioning. The treatment group showed improvement in AQLQ scores. No statistical significance between both groups in peak flow measurements
Jaakkola et al. [9)	RCT	Adult patients with asthma 16 to 65 yrs with a diagnosis of mild or moderate asthma.	Self-directed aerobic exercise at least three times a week for at least 30 min for 24 weeks. The targeted heart-rate level was 70-80% of the maximal heart rate	A total of 89 patients with asthma, with 45 in the control group and 44 in the intervention group.	Control: 39.7 (14.06) Intervention: 32.9 (10.72)	ACT self-reported symptoms PEF-measurements	In the intervention group, ACT score was improved compared to control. The risk difference was 0.233 between the groups. No difference in PEF between the groups
Evaristo et al. [10)	RCT	Outpatients with moderate-to-severe persistent asthma aged 30-65 yrs.	Indoor treadmill exercise with a target of 60% of maximal heart rate. 40 min twice a week for 12 weeks. Breathing exercises using the Pranayama Yoga technique.	A total of 54 patients with asthma, with 25 in the breathing group and 29 in the intervention group	Breathing intervention: 50.6 (9.2) Aerobic Intervention: 49.8 (9.7)	ACQ AQLQ Asthma symptom-free days Hospital anxiety and depression scale Daily-life physical activity Pulmonary function	ACQ was improved at 3-month follow-up in the aerobic group compared to the breathing group. DLPA, ASFD, psychological distress, and induced sputum were not statistically significant between the groups.
Coelhoa et al. [11)	RCT	Outpatients 18-65 yrs old with a diagnosis of asthma for at least 6 months.	Step based physical activity monitored with a pedometer for a target of 30-minute walks, 5 times a week for 12 weeks.	A total 30 patients with asthma, with 15 in the control group and 15 in the intervention group.	Control: 47 (14) Intervention: 45 (19)	Number of steps ACQ AQLQ HADS 6MWT	Daily steps and 6MWT were improved in the intervention group compared to the control group at 12 weeks follow-up. ACQ, AQLQ, HADS showed no significant difference between the two groups at 12 weeks. At 24-28 week follow-up, there were no differences between the daily steps and 6MWT.
Ma et al. [13)	RCT	Participants recruited from Kaiser Permanente medical centers from age 18-70 with a BMI greater than or equal to 30 kg/m2 with confirmation of uncontrolled persistent asthma	12-month lifestyle intervention that included goal oriented 7-10% weight loss as well as 150 min/wk of moderate-intensity physical activity.	A total of 330 patients with asthma with 165 in the control group and 165 in the intervention group.	Control: 47.7 (12.1) Intervention: 47.5 (12.6)	ACQ Weight loss and physical activity	There was no significant change in ACQ between the groups. There was significant change in weight, −5.0 kg in the intervention group compared to the control.
Toennesen et al. (10)	RCT	Adult patients with asthma from age 18-65 yrs with a BMI of more than 20 and less than 30 kg/m2	The interventions studied were exercise, diet, exercise + diet, or usual care. Exercise consisted of 10-20-30 concept on indoor spinning bikes for 20-30 min 3 times a week for 8 weeks. Diet group worked with a trained dietician to increase amount of anti-inflammatory index of foods by Shivappa et al.	A total of 125 participants completed the study. 29 were in the exercise only intervention, 33 were in the diet only, 29 were in the combined intervention, and 34 were in the control group.	Control: 38.2 (12.7) Exercise only: 39.4 (12.5) Diet only: 40.7 (14.7) Combination: 43.7 (13.9)	ACQ AQLQ Lung function Induced sputum FeNO AHR	The intervention group showed statistical significance among the combined group when compared to the control. There was no statistical significance in exercise only or diet only intervention groups. There was no statistical significance with regards to AQLQ, lung function, induced sputum, FeNO, or AHR between the two groups.
Freitas et al. [17)	RCT	Outpatients with moderate/severe asthma with a BMI greater than or equal to 35 and less than 40 kg/m2 between the ages of 30-60 years old.	Weight loss program was implemented for both arms. Aerobic and resistance exercise 2 sessions per week for 3 months with a goal of 50-75% of peak VO2 in the intervention group.	A total of 51 patients with asthma were included in the final analysis with 25 in the weight loss + sham group and 26 in the weight loss + exercise group	Control: 48.5 (9.6) Intervention: 45.6 (7.7)	VO2 ACQ AQLQ FeNO Serum anti/inflammatory markers	WL + E group had significant increases in peak VO2 compared to sham group. ACQ improved significantly in the WL + E group, WL + S group no change after intervention in ACQ. WL + E showed more improvements in specific domains of the AQLQ, WL + S group showed improvement in environmental domain. No change in FEV/FVC ratio in either group. Only WL + E group showed decrease in FeNO. Also showed reduction in CCL2, IL-4, IL-6, TNF-a, and leptin; increased levels of vitamin D, IL-10, and adiponectin.
Prossegger et al. [18)	RCT	Adults between 18-55 yrs with house dust mite sensitization and allergic asthma/rhinitis.	3-5 h guided GPS-monitored hiking/snow-shoe tours for 10 days.	A total of 40 patients with asthma were included in the final analysis with 22 in the control group and 18 in the intervention group.	Control: 31.6 (10.7) Intervention: 40.6 (12.1)	FeNO 6MWT AQLQ Nasal lavage and saccharin test Lung function	There was significant reduction in FeNO and eosinophilic cells from nasal lavage compared to control group. There was no significant change in AQLQ or lung function  between the two groups.
Scott et al. [19)	RCT	Adults with a BMI of 28-40 kg/m2 with asthma.	Dietary intervention: Prescription intake of 3700-4900 kJ/day (885-1170 kcal/day) and dietary counseling with dietitian. Exercise: 1 h aerobic and resistance training exercise three times a week for 12 weeks with daily pedometer step goals.	A total of 38 patients with asthma completed the trial. 15 were in the dietary group, 10 in the exercise group, and 13 in the combined group	Dietary intervention: 44.7 (14.7) Exercise intervention: 42.2 (11.5) Combined intervention: 33.9 (11.5)	ACQ AQLQ Lung function Inflammatory markers Anthropometric measurements Physical activity levels	ACQ was improved after dietary and combined interventions. AQLQ were improved by all interventions. Lung function: TLC increased in the exercise and combined compared to dietary alone. ERV improved after dietary. AHR did not show any significant change. Weight loss did not improve ACQ or AQLQ but improved lung function. Inflammatory markers: leptin reduced in dietary and combined, IL-6 reduced in combined only. Sputum eosinophils reduced in exercise and was significant. Physical activity: increase in mod-intense exercise reduced sputum eos and sputum eos.

ACQ: Asthma control questionnaire; AQLQ: Asthma quality of life questionnaire; PFT: pulmonary function test; SF-36: The 36-Item Short Form Health Survey questionnaire; ACT: Asthma control test; PEF: Peak expiratory flow; HADS: Hospital anxiety and depression scale; 6MWT: 6-min walk test; FeNO: Exhaled nitric oxide test; AHR: airway hyperresponsiveness.

Table 2. Summary of characteristics of prospective studies included.

Authors	Study Design	Subjects Studied	Intervention parameters, duration, frequency	Participants	Control/Intervention age, years, mean (SD)	Outcome measures	Results
Mancuso et al. [12)	Prospective	Outpatients at least 18 years of age who were diagnosed with mild to moderate persistent asthma and spoke English.	A positive affect and self-affirmation component were the intervention group. Any form of aerobic physical activity measured using the Paffenbarger Physical Activity and Exercise Index, with a goal of 336 kcal/wk for 12 months.	A total of 258 patients with asthma with 128 in the positive affirmation group and 130 in the exercise only group.	Intervention: 43 (12)	ACQ AQLQ	There was no significant increase in energy expenditure between the two groups. However, ACQ and AQLQ showed a significant improvement in both groups.
Scichilone et al. [15)	Prospective	Outpatient adults who were diagnosed with mild asthma and skin test positive to at least one aeroallergen.	40–70-minute indoor rowing training that consisted of 2-3 session per week for 10 weeks for a goal of 20% of all training time at maximal power output, 10% of time at 75-90% output, and 70% at 60-65% output.	A total of 14 patients with asthma completed the study. 5 were in the control group and 9 were in the intervention group.	Control: 26 (3.2) Intervention: 24 (2.1)	Airway responsiveness in the absence of deep inspiration Lung function	Spirometry was unaffected by exercise training. The reduction of IVC in the training group after Mch-induction was halved compared to the control.
O'Neill et al. [11)	Prospective	Moderately active adults age 18-44 yrs old with a diagnosis of asthma	20-minute bouts of HIIT exercises 3 times a week for 6 weeks, with a goal of 10% peak power output for 1 min and 90% peak power output for 1 min, repeated 10 times.	A total of 20 patients with asthma completed the study and participated in the exercise intervention.	Intervention: 22.5 (3.2)	Lung function ACQ Physical Activity Enjoyment Scale Exertional dyspnea (RPD)	ACQ showed improvement after the intervention. RPD also improved between pre and post interventions, however 4 participants were not assessed in RPD due to fatigue. PAES showed improvement as well. No statistical significance in lung function pre and post intervention.
Freeman et al. [20)	Prospective	Adult patients with asthma between 18-80 yrs old and were physically inactive as defined by ACSM guidelines.	30 min three times a week of supervised, in-hospital interval exercise training on electromagnetically braked cycle ergometer for 12 weeks. Training intensity was comprised of 3 min sessions at workload of 80% of anaerobic threshold.	A total of 24 patients were enrolled and 6 were included in the final analysis.	Intervention: 31.3 (10)	ACQ AQLQ Lung function Anthropometric data FeNO Inflammatory markers	ACQ: statistical improvement in this at the end of intervention. AQLQ showed improvements in all domains except activity domain. FVC showed improvement. FEV1 did not show any significant change. FeNO showed no significant change. Total white cell, lymphocyte, and eos counts decreased post intervention. CCL11, IL-5, TNFa and IFN reduced as well.

ACQ: asthma control questionnaire; AQLQ: asthma quality of life questionnaire; RPD: Rating of perceived dyspnea; FeNO: Exhaled nitric oxide test.

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